ASHM Report Back

Clinical posts from members and guests of the Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM) from various international medical and scientific conferences on HIV, AIDS, viral hepatitis, and sexual health.

The HIV dried blood spot test is available for individuals living in NSW who are over the age of 16 yrs. It provides another option for individuals to access HIV testing. This test is provided free (health dollar cost $12) it is designed to be mailed out, with full instructions in the kit, it is performed in the individuals own time and posted back. The average turn around time of returning a sample was 18 days. Test results were given by text if negative and a phone call if positive. At this time it has resulted in 2 positive results that may not otherwise have been diagnosed. This provides a great option to those that face barriers to screening and has been used by some individuals as a means of ongoing screening. It demonstrates the convenience of testing, the ability to remain anonymous and resulted in the screening of a diverse group of individuals.

In the session on ‘Initiation, testing and diagnosis’, Dr Mark Bloch spoke of a new device that could be used for rapid HIV self-testing. The concept of rapid HIV testing has been around for some time, however it is not yet readily available in Australia. Mark spoke of the many benefits self testing could provide: possibly increasing uptake of testing and thus diagnosis – particularly for those in hard to reach communities (there is predicted 10% undiagnosed people living with HIV in Australia), as well as increased convenience, confidentiality and sense of autonomy. Of course it is not without risk – the potential for inaccurate results, ethical risks, and potential psychological danger in the event of a positive result in an environment without clinicians readily available to answer questions.

Mark’s study looked at the usability and performance of a new device – Atomo Galileo HIV self-test. In 521 individuals, concordance of the self-test was assessed with the conventional laboratory testing, and usability was assessed by assessing accurate performance of 6 critical steps. In this study, concordance of the self-test with lab testing was essentially 100% (99.8% - the 1 discrepancy was attributed to a false positive from the lab test). There was high usability scores demonstrated by close to 90% of all individuals performing all 6 critical steps.

The device itself looked simple and intuitive. It was not too dissimilar from a glucometer or a pregnancy test – with a lancet to prick the finger and chamber to collect blood (in the same device). A single band appeared in the event of a positive result alongside a control band. The test reportedly takes approximately 15 minutes to obtain a result.

This device has potential for use in difficult to access communities and resource limited settings, and removes additional barriers to testing and diagnosis. It remains to be seen what impact HIV self-testing will have in engagement with clinics and whether this would impact adherence to regular screening guidelines for other STIs.

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Mark directs us to his website ‘HIVST.org’ for further information on HIV self-testing.

Self- Testing in HIV has been a controversial topic, and from my experience with HIV in Timor I have been very skeptical it could be successfully performed

The two sessions from Mark Bloch and Anna Mcnulty however demonstrated to me that it was a feasible and potentially useful option. First Mark Bloch spoke of advantages/disadvantages of self testing.

Self testing has many advantages. It gives people the opportunity to test themselves in a comfortable environment at a time convenient to them. They no longer need to wait hours or days for a result. And no longer need to risk multiple people being aware of their diagnosis (huge issue with health facilities in Timor, as everyone is related). It also has the added benefit of being easy to do in rural and remote environments, where people would have to travel hours to get tested.

However one of my worries has been the quality of the results, as they are more likely to be inaccurate when performed by untrained hands. on top of this the person undergoing the test may not undergo adequate counselling/ understand the significance of a positive result. Another concern centers around missing numerous other crucial tests that would also routinely be performed in those receiving HIV tests.

To my surprise however 88% of those performing a rapid HIV test in NSW were capable of following all the steps correctly (though i imagine this would be much less in a place with poor education like Timor).

Following Marks talk Anna Mcnulty went on to discuss self testing with Dry Blood Spot. This had the advantage of being easy to post to and from the household of those being tested and relatively easy to be performed. It's had a slow uptake in NSW, though the MSM community seem to be catching on.

Self-testing definitely has an important role in reaching those communities who would not otherwise engage in healthcare due to concern of confidentiality, convenience, geography and comfort.

Dr Klausner discussed using various innovative ways to increase HIV and STI testing, treatment, adherence, and prevention via the use of technology-based and online methods. The aim was to reach the hard to reach, in a way that was accessible and individuals not feel judged.

Testing occurred in various ways including in community based settings at places accessible to our frequented by hard to engage individuals such as sex workers, injecting drug users, homeless. A walk-in self testing service was set up where12,500 people per month accessed this service. The self- testing facility would allow people to go in and fill in an electronic risk assessment, print identification labels, then dispense the appropriate swabs for the self collected samples. A result would then be given in 2 hours.

Online ordering of in-home HIV and STI testing kits, and Outreach voucher programs were other ways to make testing more accessible.

To increase adherance to PrEP or ART individuals can go to online program and customise how and when they get reminders to take there medication and reminders for testing through patient engagement software. Also was noted that PLWHIV could check their CD4 counts and VL and found that there was increased medication compliance in this experience.

With regards to prevention of HIV and STI's condom vending machines were widely distributed to areas to increased accessibility to condoms. Online ordering and initiation of PrEP is an option too where individuals can go online and answer questions regarding their history and risk factors. Appropriate pathology testing would be ordersd including HIV and Hepatitis B serology. Once results are available if person is eligible to commence PrEP they are prescibed medication and it is sent to them. All done without having a face to face consult with a doctor.

One example covered was syphilis testing - recommendation that syphilis serology done with all HIV VL tests. Initial audit suggested only 25% or less of cases of HIV VL testing at Alfred were accompanied by syphilis serology. Response with clinician education was effective in improving testing to around 50%, but not durably so (decreased again after 1year). An individual clinician audit approach was more effective, and changing the system to 'opt out' (syphilis testing needed to be crossed off for it not to be done), proved successful. Food for thought regarding clinician behaviour and testing algorithms. When is an 'opt out' approach appropriate? And how does it impact on clinician responsibilities, patient rights, and health outcomes?

The next example presented by Prof Hoy concerned screening and management of HT by clinicians. Re-education was required for doctors to check BP, however surprise to realise that re-education was subsequently required to get them to do anything about the results! An important lesson, particularly given the aging HIV infected population - as presented in the last session I attended (Theme B this morning at 11:15am) and the new comorbidity focus on illnesses associated with aging including cardiovascular disease, bone mineral density changes and cognitive impairment. HIV clinician-gerontologists are uncommon, but at the very least HIV clinicians need to expand their skill sets to optimise their abilities to manage the new comorbidities seen in their patient populations.

One of the important messages presented in this talk was that audit is required to improve quality of care - shortfalls may thereby be identified at individual provider, setting and state and national levels. Quality improvement needs to be integrated into care. To make changes durable however is the next challenge.

Finally, she discussed the barriers to Quality of care, for example-the importance of setting standards for quality, as is seen in the European Guidelines , for care of PLHIV. We do not have these in Australian guidelines at the moment.

"Quality of life is inextricably linked to the quality of care that we deliver".